TB As Seen on a Chest X-Ray

TB as Seen on A Chest X-ray

Dana G. Kissner, M.D. Medical Director TB Clinical Services, Detroit Associate Professor Wayne State University TB Tri-State Clinical Intensive, Dearborn, MI, September 29, 2016 ©2014 MFMER | slide-1 Disclosures • None relevant

©2014 MFMER | slide-2 Objectives • You will • Be able to identify major structures on a normal chest x-ray • Identify and correctly name major CXR abnormalities seen commonly in TB • Recognize chest x-ray patterns that suggest TB & when you find them

Basics of Diagnostic X-ray Physics • X-rays are directed at the . patient and variably absorbed • When not absorbed • Pass through patient & strike the x-ray film or • When completely absorbed • Don’t strike x-ray film or • When scattered • Some strike the x-ray film

• Absorption depends on • Whitest = Most Dense the • Metal • Energy of the x-ray • Contrast material (dye) beam • Calcium • Density of the tissue • Bone • Water • Soft Tissue • Fat • Air / Gas • Blackest = Least Dense

Posterior Anterior Note silhouette formed by • lung adjacent to heart • lung adjacent to diaphragm

Silhouette Sign

Lifeinthefastlane.com

Hilum – Major bronchi, Pulmonary veins & arteries, Lymph nodes at the root of the lung)

Mediastinum – Central chest organs (not lungs) – Heart, Aorta, Trachea, Thymus, Esophagus, Lymph nodes, Nerves (between 2 pleuras or lining of the lungs)

• Apex of lung • Area of lung above the level of the anterior end of the 1st rib

• Paratracheal stripe • Seen between the air in the trachea & air in the lung

©2014 MFMER | slide-15 Dual Energy Digital Subtraction Techniques: Useful for nodules • Takes advantage of the • Dual Energy Technique effect of energy of x-ray can make bones fade or beam on absorption. be seen more distinctly

©2014 MFMER | slide-16 ©2014 MFMER | slide-17 Consolidation • Appears as a relatively homogeneous white area on chest x-ray • Although the terms opacity and density are sometimes used, areas of consolidation are usually translucent; structures such as ribs are visible through the consolidation • Is caused by filling of airspace with fluid, cells, pus, blood • Without significant volume loss

©2014 MFMER | slide-18 Consolidation • Air bronchogram may be visible because air in the bronchus forms a silhouette with fluid in airspace (characteristic of consolidation; not always present). • Silhouette sign occurs when opacity is contiguous with heart or diaphragm, causing loss of normal silhouette

©2014 MFMER | slide-19 Consolidation / Opacity / Density • The initial lesion in primary TB can be in any location in the lung • In later (“reactivation”) TB, location is most frequently in the upper and posterior portions of the lung • Apical and posterior segments of the right upper lobe • Apical-posterior segment of the left upper lobe • Superior segments of the lower lobes

Lingula

©2014 MFMER | slide-22 Nodules / Masses • Nodule - discrete opacity or density that is 2-30 mm in diameter • TB nodules can be • Solitary • Multiple • Associated with other chest x-ray abnormalities due to TB • A common pattern for primary TB is a nodule (the primary focus of infection) plus ipslateral enlarged mediastinal or hilar lymph node(s)

“FDG avid pulmonary nodule in the right middle lobe, along with two FDG avid lymph nodes involving the right hilum and subcarinal region. Findings suspicious for malignancy.”

©2014 MFMER | slide-28 Cavities • Most common in advanced disease (reactivation TB) • Highly contagious, contain many actively multiplying organisms • Endobronchial spread to other areas of lung • Higher risk of developing drug resistance • May take longer to treat • Wall thickness thin to medium • Significant air / fluid levels are rare

©2014 MFMER | slide-37 Miliary TB • Disseminated disease • Usually occurs during initial (primary) infection with hematogenous spread of MTB • Uniformly distributed nodules ~ 2 mm. in size • May progress to septic shock and acute respiratory failure • After infection, miliary TB &/or meningitis occur in ~ 10-20% of babies < 1 year old

©2014 MFMER | slide-41 TB Pleural Effusions and Other Abnormalities - Small to very large, can loculate - Usually unilateral - Primary (or post primary disease) - Fluid can be serous, thick & congealing, or bloody – not frank pus unless complicated - Exudate – high protein and LDH, white cells predominantly lymphocytes - ↑ Adenosine deaminase and IFN-g levels - Bronchopleural fistulas can occur

Ghon Complex

Frank Netter

©2014 MFMER | slide-51 Tracheobronchial TB • Airways can be compressed by large lymph nodes • TB can be endobronchial • Bronchiectasis and bronchostenosis are common sequelae • Atelectasis or collapse of the lung beyond an obstructing lesion can occur (similar to lung cancer)

1940

Alice Neel (1900-1984) TB Harlem

Ed Neuhauser and Ben Felson